ED Coding and Reimbursement Alert

Even after a coder in a teaching hospital learns the basics of Medicare's guidelines for reporting resident services, she often needs guidance applying those rules when a resident from another specialty is involved.

Frequently, the standard guidelines for supervising physicians in teaching settings, as found in section 15016 of the Medicare Carriers Manual, apply without complication.

Scenario: A patient is seen in the ED for a non-displaced fractured finger. Because this hospital participates in an approved graduate medical education (GME) program, it has a policy to bring in an orthopedic resident for all fracture cases. The ortho resident examines the patient and, under the direct supervision of the emergency physician, who would typically handle routine fractures, splints the finger.

Services rendered by residents in PATH (physicians at teaching hospitals) settings are decidedly circumscribed, even in straightforward circumstances. Documentation rules govern both E/M services and other procedures or services, with variations in each case.

While the only services performed by the medical student that can be used in documenting E/M services are the past, family, social history (PFSH) and review of systems (ROS), residents may gather the entire H&P as long as there is clear documentation that the physician performed and documented the key portions of the history, physical exam and medical decision-making, says Jim Blakeman, senior VP with Healthcare Business Resources Inc. in Bala Cynwyd, Pa.

Because residents often provide the entire service, with attending physicians repeating the key portions, coders should be on the lookout for markers to distinguish between the attending physician's and the resident's information.

Many hospitals have separate sections in the chart to segment documentation so coders can distinguish between the residents' handwriting and that of their attending physicians. Problems multiple like flies "when coders can't tell who did what," Blakeman notes. He recommends returning unclear charts and requesting written clarification: "As long as what is included as an addendum to the medical record is reasonably contemporary, that's an adequate note to supplement the chart."

Other procedures a resident might perform are governed largely by the service's length and complexity. Medicare considers services of three to five minutes "minor" and requires the attending physician to be physically present and "elbow-to-elbow" to the resident.

Major procedures requiring more than five minutes oblige the attending physician to document that he or she was present or performed the key portion(s) of the procedure. For example, a resident may perform all of the fracture care (e.g., 26740, Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each), but the attending must document his or her presence for the key portions of the procedure e.g., exploration of the fracture, applying the bandage, and/or inspection of the splint.

The ED attending "can't just use a little formula statement saying, 'I was present for the key portion,' " Blakeman says. Without explicit, case-specific statements, the coder needs to send the chart back to the attending physician and ask for the key portion.

As long as the ED physician documents and supervises the procedure and there is no orthopedic attending physician present the ED physician is completely justified in billing for supervising this event.

There are gray areas where the ED doctor may be competent to supervise a procedure but the resident from the outside specialty may have a higher degree of comfort.

Scenario: A patient is seen in the ED for a broken leg. The injury requires open treatment and fixation, so the ED physician calls in an orthopedic team, including one or more orthopedic residents, because the severity of the patient's injury is beyond his scope. The orthopedic attending is present for the first part of the leg repair.

In order to bill, the orthopedic attending must meet the criteria for teaching physician oversight of a major procedure. If the ED attending writes a clear note describing his presence in the room in a manner that satisfies the teaching physician (TP) rules, then from a purely by-the-book perspective he would be allowed to bill for the procedure.

However, the ED TP would have to consider whether he was truly supervising, says Michael Granovsky, MD, CPC, CFO, of Greater Washington Emergency Physicians in suburban Maryland. The general consensus in this type of case is that emergency physicians should not bill for procedures that they cannot render themselves. Coders should always clarify these murky situations with the ED physician or ED management.

As an example of when it may be technically allowable for an emergency physician to bill for specialized services performed by highly trained residents, Blakeman offers the case of the hand re-implantation team at Thomas Jefferson Hospital in Philadelphia.

Scenario: The ED at Thomas Jefferson supports a hand surgery team that attracts surgery fellows from all over the world. They are typically requested to participate in complicated re-implantation surgeries for hand crush injuries. There is not always an attending physician from surgery or orthopedics present when residents are performing the surgery.

In this case, the fellows' medical experience and specialization are secondary to the hospital's participation in a Medicare-supported GME program. The Medicare Carriers Manual specifically includes interns and fellows in the definition of a resident: "The term ["resident"] includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary."

"Even though they've been practicing for 30 years and are licensed, the fellows are participating in a teaching physician program and are getting federal money for their fellowship," Blakeman says.

In theory, as long as the ED attending meets Medicare PATH documentation and performance standards, he or she may bill for supervising complex services performed by GME fellows. However, this example serves to illustrate further that ED physicians should only bill for procedures they are qualified to perform. Where physicians draw the line tends to be an individual decision, and coders need to know their ED's preferences and policies to record resident services from outside departments with confidence and accuracy.